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A    N 

INAUGURAL   DISSERTATION 


ON      THE 


CYNANCHE   TRACHEALIS. 


SUBMITTED    TO    THE    PUELIC    EXAMINATION 
OF       THE 

FACULTY     OF     PHYSIC, 

UNDER    THE    AUTHORITY    OF     THE 

TRUSTEES    OF    COLUMBIA    COLLEGE 

IN      THE 

STATE  OF  NEW-YORK^ 
WILLIAM  SAMUEL  JOHNSON,  LL.D.  Prefident; 

FOR    THE    DEGREE    OF 

DOCTOR    OF     PH2~SIC; 

ON  THE  THIRTIETH  DAY  OF  APRIL,    I  793- 

By  SAMUEL    BORROWE, 

Citizen  of  the  State  of  New- York. 


Whence  in  bright  floods  the  vital  air  expands, 

And  with  concentric  fpheres  involves  the  lands  j 

Pervades  the  fwarming  feas,  and  heaving  earths, 

Where  teeming  Nature  broods  her  myriad  births; 

Fills  the  fine  lungs  of  all  that  breathe  or  bud  \ 

Warms  the  new  heart,  and  dyes  the  gu/hing  blood  j 

With  life's  firft  fpark  infpires  th'  organic  frame, 

And,  as  it  waftes,  renews  the  fubtile  flame.  Darwin. 


NEW-YORK: 

Printed  by  T.  and  J.  Swords,  Printers  to  the  Faculty  of  Phyfic  of 

Columbia  College,  No.  27,  William-Street. 

—  I793.— 


7$$ 


w,***^  . 


P ;.:... 


*  <*«^-i„.' 


//^ 


Imprimatur. 


Samuel  L>  Mitchill. 


GOZEN    RYERSS, 

fi.   N    V 

JOHN   C,   DON  CAN, 

o  F 

$  T  AT  |  N-2  S  I  A  N  D: 

This 

DISSERTATION 

Is  moft  refpeftfully  infcribed, 

<5y  /£«>  much  obliged  Friend* 

The  AUTHOR'. 


A  N 


INAUGURAL  DISSERTATION 


CYNANCHE  TRACHEALIS. 


JL  HERE  is  perhaps  no  difeafe  to  which  children 
are  fubjedt,  that  proves  more  certainly  detractive, 
if  left  to  nature,  than  the  Cynanche  Tracbealis.  Such 
was  its  fuppofed  fatal  nature,  that  not  long  iince 
many  have  been  fufFered  to  expire  without  calling 
in  any  medical  amftance,  as  it  was  conceived  to  be 
irremediable  -,  owing  to  the  then  unfuccefsful  me- 
thod of  treating  it. 

With  refpecl  to  the  nature  and  caufe  of  Chynanche 
Tracbealis,  there  has  lately  been  a  variety  of  opi- 
nions entertained,  which  have  given  rife  to  as  great  a 
variety  of  remedies,  and  of  very  oppofite  kinds. 

Aimed  every  Phyfician  has  had  a  different  me- 
thod of  cure.    As  they  could  not  all  be  right,  thou- 

funds 


(     6    ) 

fands  of  the  fick,  no  doubt,  muft  have  fallen  a  fa* 
crifice  to  the  difeafe,  for  want  of  medical  difcernment, 
or  by  reafon  of  a  blind  attachment  to  an  improper 
plan. 

a 

"We  have  accordingly  {qqu.  one  fet  of  men  warmly 
recommending  the  Jihenic  mode  of  cure,  prefcribing 
contrayerva,  Peruvian  bark,  &c.  with  a  view,  as 
they  exprefs  it,  of  counteracting  the  virus,  or  cor- 
recting the  tendency  of  the  fluids  to  putrefaction. 

How  much  to  be  feared  are  fuch  Practitioners, 
who,  in  fpite  of  modern  experience  to  the  contrary, 
ftill  adhere  to  that  delufive,  and  I  may  fay,  danger- 
ous fyftem,  the  humoral  pathology  I  And  how  much 
to  be  pitied  are  thofe  unfortunate  patients  who  come 
under  their  immediate  care ! 

On  the  other  hand,  we  obferve  another  fet  of  men, 
who,  with  great  propriety,  advife  the  ajlhenk  metho4 
of  cure.* 

Others  have  faid  that  there  are  two  fpecies  of  this 
difeafe,  fpafmodica  and  humid/fa.-[  That  there  may 
be  a  Cynanche  Trachealis  Spafmodica  I  will  not  at- 
tempt to  deny*  but  in  all  thofe  cafes  which  I  have 

had 

*  Cullen's  Firft  Lines,  and  a  Letter  from  Richard  Bayley,  Surgeon, 
to  William  Hunter,  M.  D. 

■j-  Rufh's  Inquiries  and  Observations,  page  iao, 


(     7     ) 

had  an  opportunity  of  obferving,  there  did  not  ap- 
pear to  be  any  thing  like  fpafm. 

In  this  DifTertation,  I  mall,  therefore,  confine  my- 
felf  to  that  fpecies  which  Do&or  Rufh  calls  Cynan- 
che  Trachealis  Humida.  I  fhall  firft  attempt  a  re- 
view of  fome  of  the  opinions  that  have  been  advanced 
with  refpecT:  to  its  nature  and  caufes,  and  then  en- 
deavour to  point  out  what  appears  to  me  to  be  the 
moll  proper  method  of  cure. 


HISTORY  of  the  DISEASE. 


THE  celebrated  Do&or  Francis  Home  has  ob- 
ferved,  that  the  Cynanche  Trachealis  is  confined  to 
the  fea  coaft,  and  mentions  as  a  proof  of  this  opi- 
nion, that  it  feldom  occurs  in  Edinburgh,  while,  in 
Leith  and  MufTelburgh  it  is  very  common.  He 
likewife  obferves,  that  it  frequently  appears  along 
the  coaft  of  Fife,  the  maritime  parts  of  Airfhire  and 
Galloway.* 

From 

*  A  Treatife  on  the  Difeafes  of  Children,  London  printed,  1772,  in 
which  there  is  an  extraft  from  Home's  Book  on  the  Croup. 

When  I  mail  have  occafion  to  fpeak  of  Home's  opinion  in  future,  I  beg 
leave  to  refer  the  reader  to  the  above  mentioned  Treatife,  as  I  have  not 
been  able  to  procure  Home's  original  obfervatfons  on  this  difeafe. 


(     8     ) 

From  thefe  fads,  Home  draws  a  general  conclu- 
sion, that  this  difeafe  is  peculiar  to  the  fea  more. 
This  I  am  difpofed  to  doubt,  for,  upon  inquiry,  it  is 
found,  that  the  Cynanche  Trachealis  frequently  pre- 
vails in  the  moft  inland  fituations.* 

I  was  lately  informed  by  Zina  Hitchcock,  a  re- 
putable Phyfician  in  Wafhington  county,  that  the 
Cynanche  Trachealis  frequently  occurred  in  the  neigh- 
bourhood of  Fort  Edward,  which  is  two  hundred 
and  twenty-one  miles  from  the  fea  more. 

Many  more  facts  on  this  head  might  be  mention- 
ed; but  I  conceive  thofe  already  ftated  fufficient  to 
do  away  the  opinion  of  Home,  with  refpedt  to  this 
difeafe  having  a  necejfary  connection  with  maritime 
regions. 

In  another  place  Home  has  aflerted,  that  the  Cy- 
nanche Trachealis  only  occurs  in  the  colder  feafons. 
This  is  erroneous,  for  it  is  known  to  prevail  in  the 
heat  of  fummer.f  There  is  no  fituation,  no  climate, 
nor  feafon  exempt  from  it.  But  I  have  obferved, 
that  it  more  frequently  prevails  during  thofe  feafons 
iri  which  there  are  the  greater!:  viciffitudes. 

There 

*  Cullen's  Firfl;  Lines  of  the  Practice  of  Phyfic. 

y  This  fact  was  communicated  to  me  by  Dr.  Samuel  L.  Mitchill,  one 
of  whofe  brothers  died  of  this  difeafe  in  the  month  of  Auguft, 


(     9     ) 

There  has  been  much  difpute  about  the  feat  of 
this  difeafe.  Some  have  fuppofed  its  fituation  to  be 
in  the  glottis;  others,  that  it  was  feated  in  the 
trachea  only.*  Directions,  however,  prove  that 
it  is  not  confined  to  the  glottis  and  trachea  alone, 
but  that  it  extends  into  the  extreme  branches  of  the 
bronchia.-\ 

The  Cynanche  'Trachealis  may  be  faid  to  be  pecu- 
liar to  children,  as  it  is  never  known  to  attack  per- 
fons  after  the  age  of  twelve  or  fourteen  years. 

This  difeafe  has  been  confidered  as  contagious  jt 
but  from  the  obfervations  which  I  have  been  able  to 
make,  it  does  not  appear  to  depend  in  any  degree  on 
contagion.  I  have  never  {qqvi  an  inftance  in  which 
it  appeared  to  be  communicated  from  one  perfon  to 
another,  although  they  were  placed  in  a  fituation 
favourable  to  receive  it,  had  there  been  any  contagion. 

From  thefe  circumftances  I  am  induced  to  con- 
clude, that  this  difeafe  is  not  to  be  confidered  as  con- 
tagious;  and  therefore,   does  not  require  all  that 
B  caution 

*  Treatife  on  the  Difeafes  of  Children,  page  154. 

f  Dr.  Bard's  Inquiry  into  the  Nature,  Caufe,  and  Cure  of  Angina 
Suffbcativa,  page  22. 

J  Bard's  Inquiry,  &c. 


(    io   5 

caution  that  was  formerly  taken  of  keeping  healthy 
children  apart  from  thofe  labouring  under  Cynancbe 

1'rachealis. 

It  is  not  uncommon  for  this  difeafe  to  attack  the 
fame  child  repeatedly.  Whether  this  proceeds  from 
the  force  of  habit,  or  from  the  peculiar  irritability 
of  the  child,  I  mall  not  attempt  to  determine.  The 
latter  however  appears  to  be  the  mofl  reafonable  con- 
jecture. 


DIAGNOSIS. 


CULLEN^,  m  his  Synopfts  Nofologia  Methodic*, 
has  placed  this  difeafe  in  the  clafs  of  Pyrexia,  and 
order  of  Phlegmajia.  As  the  pathognomonick  fymp- 
toms  are  collectively  viewed  in  the  definition,  I  here 
give  it  m  the  words  of  that  learned  Nofologift. 

"  Refpiratione  difficili,  infpiratione  ftrepente,  voce 
rauca,  tuffi  clangofa,  tumore  fere  nullo  in  faucibus 
apparente,  deglutitione  parum  difficili  et  febre  fy- 

nocha."* 

The 

*  Culleni  Synopfis  Nofolpgise  Metfiodics. 


f   II   ) 

The  moft  diftinguifhing  chara&eriftics  of  Cynan- 
che  Tracbealzs,  are  the  hoarfe  dry  cough,  and  fhrill 
'found  in  infpiration,  which  is  compared  to  air  pafTmg 
through  a  brazen  tube*  to  the  crowing  of  a  young 
cock\\  and  it  is  likewife  faid  to  be  fimilar  to  the 
barking  of  a  young  dog.\  Together  with  thefe 
fymptoms  there  is  a  pain  about  the  larynx?  great  dif- 
ficulty of  refpiration,  and  a  fenfe  of  fufFocation  •,  the 
cough  is  remarkably  dry,  the  pulfe  is  for  the  niofl 
part  frequent,  and  the  patient  is  extremely  uneafy, 
continually  throwing  the  arms  and  legs  about,  fre- 
quently turning  from  fide  to  fide,  often  placing  the 
hands  to  the  throat,  as  if  he  was  choaking,  In  the 
earlier  ftages  of  this  complaint,  the  face  is  confidera- 
bly  flufhed;  but  in  the  latter  ftages,  it  becomes  pale 
and  frequently  of  a  livid  appearance,  As  the  difeafe 
advances,  there  comes  on  a  difpofition  to  fleep,  which 
appears  to  be  produced  in  part,  by  the  ftrength  be- 
ing exhaufted,  in  confequence  of  the  great  anxiety 
and  ftruggling  of  the  patient,  whereby  the  circula- 
tion ultimately  becomes  languid.  If  roufed  from 
this  apparent  fleep,  the  uneafinefs  is  considerably  in- 
creafed  in  confequence  of  the  circulation  being  quick- 
ened j  whereby  a  greater  quantity  of  blood  is  fent  to 

the 

*  Cullen's  Firft  Lines  of  the  Pra&'ce  of  Phyfic, 

■\  Bard's  Inquiry,  &c. 

$  Rufh's  Qbf?rval;ions,  &c. 


(    n    ) 

the  lungs  in  a  given  time.  Together  with  thefe 
fymptoms,  the  difficult  refpiration  continues  to  in- 
creafe,  which,  in  a  very'  fhort  time,  terminates  the 
exiftence  of  the  unfortunate  patient. 

This  is  the  common  courfe  of  Cynanche  Trachealis 
if  left  to  nature,  and,  I  fear,  too  frequently  when  a 
cure  is  attempted. 

Rum  mentions  that  there  are  fmall  red  blotches 
fometimes  obferved  on  the  fkin.  This  I  confider  as 
an  accidental  occurrence,  and  therefore  not  requiring 
any  particular  attention. 

It  is  faid  that  the  fauces  are  fwelled  and  fomewhat 
inflamed.*  That  this  may  fometimes  take  place,  I 
Jfhall  not  attempt  to  deny ;  but  I  have  never  been 
able  to  difcover  the  leaft  appearance  of  inflammation 
or  fwelling  in  the  fauces,  though  I  have  been  par- 
ticularly careful  in  examining  a  number  of  patients 
with  the  Cynanche  Tracbealis,  while  I  was  under  the 
tuition  of  the  late  celebrated  Phyflcian  and  extenflve 
Practitioner,  Charles  M'Knight ;  and  likewife  thofe 
patients  that  have  fince  come  under  my  care. 

It  is  mentioned  that  the  Cynanche  Trachealis  comes 
on  with  the  ufual  fymptoms  of  a  common  catarrh.-j- 

I  rather 

*  Cullen's  Firft  Lines. 

■f  Cullen's  Firft:  Lines,  vol.  i.  page  352. 


(    n   ) 

I  rather  fuppofe  this  to  be  a  miftake,  for  I  have  feea 
many  children  in  the  earlieft  ftages  of  this  difeafe^ 
and  the  peculiar  fymptoms  that  are  above  enumer 
rated  were  the  firft  appearance  of  indifpolitiom 


REMOTE   CAUS^ 


THE  remote  caufes  may,  perhaps,  with  fome 
degree  of  propriety,  be  divided  into  the  predifpo- 
nent  and  occafional. 

The  predifponent  caufe  appears  to  me  to  be  a 
certain  irritability  peculiar  to  children,  as  the  Cynan- 
che  Trachealis  is  never  known  to  attack  a  perfon  af- 
ter the  age  above  mentioned,  viz.  twelve  or  fourteen 
years. 

"With  refpecl:  to  the  occafional  or  exciting  caufe, 
there  are  many  opinions.  Home  fuppofes  that 
the  peculiar  ftirnulus  of  the  air  near  the  fea,_  may 
be  confidered  as  the  occafional  caufe.  The  marine 
air  (fays  he)  fupplies  a  ftirnulus  calculated  to  increafe 
the  fecretion  of  mucus  from  the  glands  of  the  trachea 
and  lungs.  He  fuppofes  that  a  great  quantity  of  fea 
fait  is  carried  into  the  atmofphere,  which  being  in- 
fpired  into  the  kings,  ftimulates  the  orifices  of  the 

glands 


(     H     ) 

glands  difperfed  on  the  internal  furface  of  the  trachea 
and  bronchia,  and  thereby  increafes  the  fecretion  of* 
mucus,  which  forms  the  preternatural  membrane. 

This  is  ingenious  theory  •,  but  I  believe  it  will  be 
found  contrary  to  fad.  The  only  cafe  in  which  ma- 
rine fait  is  fufpended  in  the  atmofphere,  is  when  the 
furf  is  very  great,  and  the  fpray  is  forced  by  the  wind 
to  a  confiderable  diftance  from  the  fhore,  as  happens 
on  the  fouth  fide  of  Lang-I/land,  where  the  fpray  is 
carried  to  the  diftance  of  feveral  miles  on  the  land ; 
fb  that  a  briny  fluid  in  fome  cafes  trickles  in  drops 
from  the  leaves  of  the  trees.  Notwithstanding  that 
the  air  is  fo  greatly  impregnated  with  faline  particles, 
this  difeafe  is  not  found  to  be  more  rife  there  than 
in  the  moft  inland  fttuations. 

This  holds  good  with  refpect  to  many  parts  of  the 
Wefi-IndieSy  as  in  Turk's- I/land,  &c.  where  the  fhore 
is  continually  warned  by  the  fea.  But  I  cannot  learn 
that  the  Cynanche  Trachealis  is  more  frequent  there 
than  in  the  places  more  remote  from  the  fea  coaft. 

From  the  foregoing  considerations  I  am  induced 
to  conclude,  that  the  fea  air  is  not  the  occafional  caufe 
of  this  difeafe  ;  that  is,  from  the  fait  it  contains. 

After  a  fair  and  candid  examination  of  the  occa-. 
iional  caufes  of  Cynanche  Trachealis,  I  am  inclined  to 

thinly 


I     %6    ) 

think,  with  Cullen,  that  the  principal  are  cold  and 
moifture  applied  to  the  body  which  was  previoufly 
much  heated.  This  accounts  for  this  difeafe  occur- 
ring moft  frequently  when  the  greater!;  viciflitudes 
of  weather  take  place. 


PROXIMATE    CAUSE. 


THE  proximate  caufe  of  difeafes  has  hitherto  es- 
caped, and  probably  will  for  a  long  time  continue  to 
elude  the  moft  accurate  refearches  of  man.  It  is 
therefore  with  the  greateft  diffidence  that  I  mall  offer 
an  opinion  on  this  fubject. 

The  proximate  caufe  of  Cynanche  Trachealis  has 
been  fuppofed  to  be  an  inflammatory  action  of  the 
veffels  on  the  internal  furface  of  the  trachea.  This 
fuppofition  does  not  by  any  means  account  for  all  the 
phenomena,  and  is  indeed  contrary  to  fact;  for 
directions  prove  that  there  is  no  primary  inflamma- 
tion in  the  Cynanche  1'rachealis. 

Ronaldus  Martin,  Profeflbr  of  Anatomy  at 
Stockholm,  difcovered  by  difTection  that  this  preter- 
natural membrane  extended  even  into  the  moft  mi- 
nute ramifications  of  the  bronchia ;  where  it  refem- 

bled 


(     16     ) 

bled  the  membrane  that  lines  an  egg-mell.     In  this 
cafe  there  was  not  the  leart  veftige,  of  inflammation 
m  the  trachea  or  lungs*     Bard  likewife  mentions  fe- 
veral  directions  which  he  made  of  patients  who  died 
of  Cynanche  Tracbealis,   in  which  the  preternatural 
membrane  was  completely  formed  j  and,  in  moft  of 
thofe  cafes,  there  was  not  the  lean:  appearance  of  in- 
flammation.    He  mentions  alfo  the  cafe  of  a  patient 
who  died  in  confequence  of  an  inflammation  of  the 
trachea,  and  on  direction  there  was  not  any  of  this 
membrane  formed.     Here  then  there  is  both  a  pofl- 
tive  and  a  negative  proof,  that  inflammation  is  not 
the  caufe  of  the  before  mentioned  membrane.    Rum. 
makes  the  following  obfervation:  "  I  acknowledge 
that  I  have  generally  (ten  both  fpecies  that  have  been 
mentioned,  without  inflammatory  fymptoms,   and 
fometimes  without  fever,  efpecially  in  the  firft  ftage 
of  the  difeafe."-f     In  thofe  cafes  which  are  faid  to 
be  attended  with  inflammation,  I  confider  it  as  an 
effect  of  the  mechanical  action  of  the  preternatural 
membrane  on  the  tender  and  delicate  furface  of  the 
trachea. 

It  has  been  aflerted  that  the  Cynanche  Tracbealis 
depended  on  a  difpofition  to  putridity  •,  in  confequence 

of 

*  Bard's  Inquiry  into  the  Nature,  Caufej  .and  Cure  of  Angina  Suffo- 
cativa,  page  22. 

•f  Rufh'a  Obfervations  and  InquirieSt 


(     *7     ) 

of  which,  there  was  fuch  a  ftate  of  the  veflels  on 
the  internal  furface  of  the  trachea  induced,  as  caufed 
them  to  effufe  a  fluid  which  is  difpofed  to  infpifiate. 

If  I  mould  for  a  moment  admit  the  improbable 
idea  that  there  is  a  putrid  ftate  of  the  body,  I  mould 
then  afkthofe  who  contend  for  this  opinion,  how  they 
can  account  for  the  formation  of  the  morbid  mem- 
brane that  is  constantly  found  in  the  trachea  and  Iron- 
chia  of  patients  who  have  died  of  this  difeafe.  If 
there  is  a  putrid  ftate  induced,  there  is  of  courfe  a 
diminished  cohefion  of  the  particles  of  matter.  If 
there  is  a  want  of  cohefion  in  the  component  parts 
of  the  body ;  or,  in  other  words,  if  the  folids  and 
fluids  are  in  a  diflblved  ftate,  as  was  formerly  faid, 
how  is  it  poffible  for  them  to  fecrete  a  fubftance  which 
is  poflefled  of  fo  great  a  degree  of  tenacity  as  the 
membrane  before  mentioned?* 

If  we  carefully  attend  to  the  hiftory  of  this  difeafe, 
we  fhall  find  that  there  is  no  fymptom  of  putridity 
attending  it,  except  the  debility  that  accompanies  the 
laft  ftage  mould  be  confidered  as  fuch,  which  can  be 
accounted  for  more  rationally  than  on  the  fuppofition 
of  the  body's  being  in  a  putrid  ftate.     Independent 

C  of 

*  Bard,  in  his  Inquiry  into  the  Nature,  Caufe,  and  Cure  of  Angina 
SufFocativa,  obferves,  that  this  membrane  is  fomewhat  fimiiar  to  Sham- 
moy  leather. 


(     18     ) 

of  any  reafoning  on  this  fubject,  the  remedies  to 
which  the  Cynanche  T'rachealis  is  found  to  yield,  af- 
ford fufficient  proof  that  it  is  not  a  putrid  difeafe. 

From  what  I  have  been  able  to  obferve,  I  am  of 
opinion  that  the  proximate  caufe  of  Cynanche  Tra- 
chealis  is  a  peculiar  morbid  action  of  the  veffels  on 
the  internal  furfaceof  the  trachea  and  bronchia,  where- 
by a  fluid  is  fecreted  which  forms  the  tough  mem- 
brane. 

The  next  object  is  to  afcertain  what  the  real  nature 
of  this  membrane  is.  It  is  fuppofed  by  fome,  to 
be  infpiffated  mucus,*  and  by  others,  coagulable 
lymph,  f 

I  am  not  willing  to  admit  the  mppofition  of  its 
being  mucus ;  for  I  know  of  no  fact  or  experiment 
by  which  it  is  evinced  that  mucus  can  acquire  fuch  a 
degree  of  cohefion  as  this  membrane  is  found  to  pof- 
fefs,  in  fo  fhort  a  time,  viz.  a  few  hours.  If  it  is 
mucus,  why  does  not  every  child  that  labours  under 
a  common  catarrh  get  the  Cynanche  Trachealis? 
And  why  does  it  not  attack  adults  ? 

Thefe  are  objections  to  its  being  mucus,  which  I 
conceive  it  is  not  eafy  to  remove.     It  may  not  be 

improper 

♦  Bard's  Inquiry,  &c.    RuTh's  Obfervations;  and  Home  on  the  Croup. 
■f-  Bayley's  Letter  to  Dr.  Hunter. 


(     i9     ) 

improper  to  obferve,  that  the  gaflric  juice  is  not  ca- 
pable of  afting  on  this  membrane,  Or  of  producing 
any  change  in  it,  while  mucus  is  perfectly  difiblved 
in  the  ftomach. 

It  is  found  that  children  who  have  recovered  from 
the  Cynanche  Tracbealis,  have,  for  feveral  days,  paf- 
fed  in  their  ftools  large  portions  of  this  membra- 
nous fubftance,  which  retained  a  great  fhare  of  its 
former  tenacity, 

This  fact  wasfome  time  flnce  communicated  to  me 
by  Dodor  Samuel  L.  Mitchill ;  fince  which;,  I  have 
had  an  opportunity  of  obferving  it  in  feveral  cafes 
which  came  under  my  care. 

In  this  way  we  may  account  for  the  recovery  of 
children  who  have  not  thrown  up  the  membrane 
in  the  act  of  vomiting ;  for,  as  they  coughed  it  from 
their  lungs,  it  was  immediately  taken  into  the  fto- 
mach. 

This  membrane  not  appearing  on  giving  an  emetic, 
has  given  rife  to  an  opinion  that  it  is  not  formed  in 
every  cafe  of  Cynanche  Trachealis ;  and,  in  all  proba- 
bility, has  induced  many  to  fuppofe  that  this  difeafe 
was  fpafmodic, 

That  this  morbid  membrane  is  compofed  of coagu- 
lable  lymph,  I  am  difpofed  to  deny  j  for  the  co> 

agulable 


(       20       ) 

agulable  lymph  is  never  feparated  from  the  blood  in 
a  ftate  difpofed  to  affume  a  membranous  form  in  the 
body,  except  in  cafes  of  great  inflammation,  which 
is  proved  does  not  take  place  in  this  difeafe.  As  a 
further  evidence  that  no  primary  inflammation  takes 
place  in  this  difeafe,  it  may  not  be  improper  to  ob- 
ferve,  that  the  blood,  when  drawn  from  a  vein,  under 
the  moft  favourable  eircumftances,  to  produce  a  fe- 
paration  of  gluten,  does  not  mew  any  tendency  of 
that  kind,  at  any  ftage  of  the  difeafe  •,  and  it  is  al- 
lowed, that  in  every  cafe  of  considerable  inflamma- 
tion or  predifpofitionto  it,  that  the  blood,  when  taken 
from  a  large  orifice,  in  a  full  ftream,  fhews,  when 
cold,  a  portion  of  its  gluten  feparated. 

I  mall  here  take  the  liberty  of  inquiring  into  the 
propriety  of  Cullen's  placing  this  difeafe  in  the  order 
of  Phlegmasia? :  his  definition  of  which  is, 

"  Febris  fynocha,  phlogofis;  vel  dolor  topicus, 
fimul  laefa  partis  internae  functione ;  finguis  miflus, 
et  jam  concretus  fuperficiem  coriaceam  albam  often- 
dens." 

Here,  then,  is  certainly  a  miftake ;  for  the  Cynan- 
che  Trachealis  is  deficient  in  two  of  the  principal 
characleriftics  of  the  order  in  which  it  is  placed,  viz. 
inflammation,  and  the  buffy  appearance  of  the  blood. 

From 


(  «  ) 

From  taking  this  view  of  the  mbject,  I  am  in- 
clined to  think  that  this  membranous  lining  which  is 
fo  conftantly  found  within  the  trachea  and  bronchia 
of  thofe  who  have  died  of  Cynanche  Tracheal^  is 
neither  infpiflated  mucus  nor  coagulable  lymph,  but 
a  fubftance  fui  generis^  produced  by  the  peculiar 
morbid  action  of  the  veflels  on  the  internal  furface 
of  the  trachea  and  bronchia. 


PROGNOSIS. 


THE  prognosis  of  this  difeafe  is  principally  to 
be  drawn  from  the  difficulty  of  breathing,  and  the 
peculiar  fhrill  found  in  the  a£t  of  inspiration,  toge- 
ther with  the  dry  cough. 

When  the  refpiration  becomes  very  laborious, 
cough  dry,  and  the  difeafed  peculiarity  of  the  voice 
is  conliderable,  we  may  conclude  the  patient  to  be 
in  an  extremely  dangerous  condition.  If  thefe  fymp- 
toms  continue  to  increafe,  and  the  face  becomes  pale, 
or  puts  on  a  livid  appearance,  the  pulfes  fink,  and 
there  mould  be  other  marks  of  great  debility,  we 
may  venture  to  prognosticate  certain  death. 

On  the  contrary,  if  the  cough  is  moift,  or  attend- 
ed with  expectoration,  the  refpiration  free  and  eafy, 
we  may  with  fome  degree  of  certainty  predict  a  fa- 
vourable termination. 

EXPLANATION 


(      22      } 

EXPLANATION  ot  th?  SYMPTOMS, 


HOME  divides  this  difeafe  into  two  ftages,  the 
firft  inflammatory,  the  fecond  putrid.  What  could 
have  induced  him  to  make  this  groundlefs  and  need- 
lefs  division,  I  can  fcarcely  imagine,  fince  it  is  found 
on  direction,  that  neither  inflammation  nor  putridity 
are  attendant  on  the  Cynanche  Trachealis. 

That  there  is  a  ftage  of  excitement  and  a  ftage  of 
debility,  I  am  willing  to  admit.  But  they  can  be 
accounted  for  on  the  true  laws  of  the  Animal  Eco- 
nomy^ better  than  on  the  fuppofition  of  inflammation 
and  its  confequence,  putridity. 

I  mall  attempt  to  account  for  the  firft  ftage  of 
Cynanche  Trachealis,  or  what  Home  calls  the  inflam- 
matory ftage,  in  the  following  manner :  When  a 
child  is  attacked  with  this  difeafe,  he  is  extremely  urt- 
eafy,  and  continually  turning  from  fide  to  fide.  This' 
reftleflhefs  ca'ufes  fome  confiderable  increafe  of  the 
circulation,  and  the  face  becomes  flufhed.  Thefe 
fymptoms  have  given  rife  to  the  opinion  that  there" 
was  really  inflammation  prefent.  But  it  is  well 
known  that  all  thefe  fymptoms  may,  and  do  fre- 
quently occur,  without  inflammation,  as  in  the  hot 
ftage  of  an  intermittent  fever. 

The 


(     23     ) 

The  ftage  of  debility,  or  that  which  Home  calls  pu- 
trid, may  be  accounted  for  in  this  way :  The  mor- 
bid membrane  that  is  found  lining  the  trachea  in  this 
difeafe,  extends  into  the  moft  minute  ramifications 
of  the  bronchia.  The  bronchia  being  thus  coated 
with  adenfe  expansion,  the  air  cannot  perform  its  pro- 
per operation  upon  the  blood  in  the  lungs.  Hence 
no  decompofition  of  the  refpirable  part  of  this  fluid 
takes  place  •,  and  of  courfe  the  circulating  mafs  does 
not  become  oxygenated.  The  want  of  oxygene  in  the 
blood  may  be  the  caufe  of  the  livid  appearance  of 
the  face  in  the  latter  ftages  of  this  difeafe. 

As  the  membrane  extends  into  the  minute 
branches  of  the  bronchia,  the  difficulty  of  breathing 
increafes,  which  cannot  be  explained  on  the  fuppo- 
fition  of  putridity  •,  but  can  very  clearly  be  accounted 
for,  by  fuppofing  that  the  blood  is  deprived  of  its 
natural  ftimulus,  the  oxygene,  or  bafe  of  vital  air. 
This  likewife  accounts  for  the  feeble  ftate  of  the 
pulfe  in  the  advanced  ftage  of  the  Cynanche'Trachealis ; 
for  it  is  a  well  eftablifhed  fad:,  that  the  circulation 
and  energy  of  the  fyftem  depends  on  the  refpira- 
tion.  Confequently,  if  the  refpiration  is  in  any  con- 
fiderable  degree  affe&ed,  debility  muft  enfue,  and 
all  the  vital  functions  flirTer  an  interruption  in  pro- 
portion to  the  degree  of  obftru&ed  refpiration.     I 

therefore 


(       24       ) 

therefore  fuppofe,  that  moft  patients  who  die  of  Cy- 
nanche  Tracbealis,  expire  in  confequence  of  a  fub- 
du&ion  of  that  ftimulus  which  is  necefiary  for  the 
fupport  of  animal  life,  and  not  by  fpafm*  or  putri- 
dity.f 


METHOD  of  CURE. 


THE  firft  indication  of  cure  in  Cynanche  'Trachea- 
lis,  is  to  deplete  the  fyftem,  which  is  moft  effectu- 
ally done  by  letting  blood,  in  confiderable  quantity, 
from  the  jugular  vein,  arm,  or  any  part  moil  conve- 
nient; but  the  jugular  is  to  be  preferred.  The  ve- 
na? fection  mould  be  repeated,  if  there  are  marks  of 
a  full  habit,  or  if  the  difficulty  of  breathing  mould 
not  be  relieved  by  the  firft  operation. 

"When  I  recommend  blood-letting,  it  is  on  a  dif- 
ferent principle  from  that  on  which  it  is  commonly 
advifed  in  this  difeafe,  viz.  that  of  abating  inflam* 
mation  •,  which,  I  have  endeavoured  to  prove,  does 
not  originally  accompany  this  difeafe,  nor  eflentially 
appertain  to  it. 

It  muft  be  allowed  that  refpiration  becomes  necef- 
iary  in  proportion  to  the  quantity  of  blood  contained 

in 

*  Bayley's  Letter  to  Dr.  Wm.  Hunter. 
+  Home  on  the  Croup. 


{     25     ) 

in  the  fyftem.  If  we  diminifh  the  quantity  of  blood, 
of  courfe  refpiration  becomes  lefs  neceffary.  Hence 
a  perfon  breathes  more  freely,  in  confequence  of  a 
fmaller  quantity  of  blood  pafling  through  the  lungs 
in  a  given  time.  In  proportion  to  the  greater  or 
fmaller  quantity  of  blood  which  paries  through  the 
lungs,  the  prefence  of  vital  air  becomes  more  or 
lefs  neceflary  to  oxygenate  it;  for  without  oxygene 
life  cannot  exift. 

In  this  difeafe,  the  oxygene  is  with  extreme  diffi- 
culty, and  in  fmall  quantity  communicated  to  the 
blood,  in  confequence  of  the  interposition  of  the 
filmy  concretion  which  invefts  the  bronchia.  If  this 
is  admitted,  we  can  account  for  the  great  relief 
which  blood-letting  affords  patients  affected  with 
Cynanche  Tracbealis,  which  is  almorl:  inftantaneous, 
and  therefore  cannot  be  accounted  for  upon  the  fup- 
pofition  of  this  difeafe  being  inflammatory.  Blood- 
letting may  be  of  fervice  in  another  way.  We 
know,  that  when  blood  is  drawn  from  the  human 
body  in  confiderable  quantity,  and  that  in  a  fhort 
fpace  of  time,  its  effecls  are  very  great.  The  change 
thus  brought  about  in  the  fyftem,  by  the  rapid  eva- 
cuation of  blood,  may  operate  on  the  vefTels  of  the 
trachea  and  bronchia  in  fuch  a  manner  as  to  induce  an 
action  in  them,  contrary  to  that  which  exifts  in  the 
D  morbid 


(       26       ) 

morbid  ftate,  and  in  this  way  cure,  or  at  leafl  pre- 
vent the  increafe  of  this  difeafe.  Emetics  are  then 
to  be  given,  to  throw  off  the  tough  matter  from 
the  lungs  and  trachea.  The  propriety  of  giving 
emetics,  in  Cynanche  Trachealis,  has  been  doubted  by 
Home.  He  fuppofes  that  emetics  promote  the  fe- 
cretion  of  mucus  in  the  lungs,  without  caufing  it  to 
be  evacuated,  and  in  this  way  increafes  the  complaint. 
This  reafoning  will  not  do,  for  I  think  there  is  the 
higher!  improbability  that  mucus  does  produce  the 
peculiar  membrane. 

Throwing  a/ide  all  theory,  the  great  fuccefs  that 
conftantly  attends  the  ufe  of  emetics  in  Cynanche 
Tracbealis,  is  fufficient  to  recommend  them  as  power- 
ful remedies.  There  are  many  inftances  in  which 
the  early  adminiftration  of  an  emetic  has  totally 
removed  the  complaint  in  the  fpace  of  a  few  hours, 
by  caufing  the  patient  to  difcharge  the  membrane 
from  the  trachea ;  and  in  other  cafes  has  caufed  a 
loofening  or  feparation  of  it ;  and  afterwards,  by  the 
effort  of  coughing,  it  has  been  entirely  brought  off. 
In  children  who  are  fo  young  that  they  have  not  the 
power  or  understanding  to  expectorate,  it  has  been 
taken  into  the  ftomach,  and  after  fome  time  makes  its 
appearance  in  their  ftools,  as  has  been  before  obferved. 
Beiides  the  effecl:  of  throwing  off  this  membrane, 

emetics 


(     27     ) 

emetics  produce  a  great  revolution  in  the  fyftem,  by 
the  concuffion  they  give  the  whole  body ;  they  mull: 
of  courfe  have  a  great  tendency  to  interrupt  or  alter 
that  peculiar  morbid  action  of  the  veffels  on  the  in- 
ternal furface  of  the  trachea.  Emetics  likewife  de- 
termine to  the  furface  of  the  body,  and  keep  the 
bowels  regular  •,  two  circumftances  of  very  great  con- 
fequence  in  the  cure  of  this  difeafe, 

The  fleam  of  warm  water  has  been  highly  recom- 
mended to  be  taken  into  the  trachea^  with  a  view  to 
difTolve  this  membrane.  This  I  confider  as  an  inlig- 
nificant  remedy,  for  it  has  been  found  that  even  the 
maceration  of  this  membrane  jn  warm  water  for 
feveral  days,  has  had  little  or  no  effect  in  deftroying 
its  tenacity.  Befides,  it  is  a  remedy  that  cannot  be 
ufed  but  with  extreme  difficulty,  particularly  with 
young  children.  I  therefore  think  it  may  with  pro- 
priety be  neglected,, 

A  bliftering  planter  is  next  to  be  applied  to  the 
throat,  which,  by  determining  to  the  furface,  af- 
fords great  relief  in  Cynanche  Trachealis,  and  appears 
to  be  well  calculated  to  produce  the  change  fo  de- 
firable  in  this  difeafe.  There  is,  however,  one  very- 
great  difadvantage  fometimes  refulting  from  the  ap- 
plication of  blifters  to  the  throat :  They  are  apt  to 

produce 


(       28       ) 

produce  difagrceable  ulcers,  which  often  end  in  mor- 
tification and  confequent  death.  The  occurrence  of 
thefe  ulcers  may  be  accounted  for  from  the  parts  be- 
ing kept  in  continual  motion,  by  the  uneafinefs  of 
the  child,  which  expofes  the  bliftered  furface  to  the 
continual  action  of  the  air.  This,  joined  to  the 
friction,  produces  irritation  and  inflammation,  which 
fometimes  terminate  in  mortification.  I  therefore 
think  that  blifters  mould  be  applied  with  the  greateft 
caution,  and  not  fuffered  to  remain  on  longer  than 
merely  to  act  as  rubefacients. 

Calomel  has  been  much  recommended,  particularly 
by  Rum.*  In  what  manner  calomel  acts,  is  not 
eafily  explained.  I  fuppofe,  however,  it  is  not  by 
correcting  acrimony,  as  has  been  imagined;-}-  for 
calomel  occafions  a  happy  change  in  fo  fhort  a  time, 
that  it  appears  impofTible  for  it  to  be  abforbed,  and 
in  that  way  produce  its  effects.  I  rather  fuppofe, 
that  it  acts  in  the  manner  which  Rufh  obferves, J 
or,  that  it  acts  by  ftimulating  the  ftomach  and  bow- 
els, which  caufes  a  derivation  to  them,  whereby  the 
morbid  action  of  the  vefTels  on  the  internal  furface  of 

the  trachea  is  interrupted. 

The 

*  Ruin's  Inquiries,  &c. 

-j-  Bard's  Inquiry,  &c. 

%  "  In  what  manner  does  calomel  a£i  in  this  diforder  ?  Is  it  by  In- 
ee  creafing  the  fecretion  of  mucus  in  the  numerous  glands  of  the  fauces, 
"  sefophagus,  fiomacb,  and  bowels 5  and  thereby  leffer.ing  the  excretion 
(l  of  it  in  the  trachea  ?". 


(  *9  ) 
The  warm  bath  is  a  remedy  on  which  great  de- 
pendence is  to  be  placed ;  for,  by  its  great  power  of 
determining  to  the  furface  of  the  body,  it  is  found 
to  relieve  the  difficulty  of  breathing  which  con- 
ftantly  accompanies  this  difeafe. 

The  cure  of  Cynanche  'Trachealis  is,  therefore,  to 
be  effected  by  the  remedies  already  mentioned,  viz. 
blood-letting,  blifters,  emetics,  warm  bath,  and 
calomel. 

As  a  proof  of  the  propriety  of  the  plan  I  have 
recommended,  I  will  fubjoin  five  cafes  of  Cynanche 
Trachealis  which  were  fuccefsfully  treated  by  it. 


CASE     I. 


ON  the  20th  December,  1792,  a  fon  of  Mr. 
Farrier,  aged  two  years,  was  attacked  with  a  hoarfe, 
dry  cough,  and  great  difficulty  of  breathing.  The 
mother  put  the  child  into  a  warm  bath ;  but  finding 
the  fymptoms  increafed,  at  two  o'clock,  P.  M.  fent 
for  Doctor  Hamerfley,  who  directed  a  gentle  emetic, 

which 


'(     30     ) 

which  operated  very  well.  At  three  o'clock  the 
Doctor  requeued  me  to  vifit  the  child  with  him :  as 
we  found  him  labouring  under  all  the  fymptoms  of 
a  diftindly  marked  Cynanche  Trachealis,  we  judged 
it  advifable  to  let  blood;  four  ounces  were  taken 
from  the  jugular  vein.  The  warm  bath  was  repeat- 
ed; after  which  the  fymptoms  were  fomewhat  re- 
lieved :  we  then  ordered  four  grains  of  emetic  tartar 
to  be  diflblved  in  four  ounces  of  water,  and  directed 
two  drachms  of  the  folution  to  be  taken  every  fifteen 
minutes  till  it  operated  as  an  emetic.  This  caufed 
the  child  to  throw  up  a  great  quantity  of  vifcid  mat- 
ter; produced  a  moifture  on  the  fkin,  and  opened  his 
bowels.  At  nine  o'clock  we  vifited  him  again.,  and 
directed  the  emetic  folution  to  be  repeated ;  half  an 
hour  afterwards  the  child  was  feized  with  a  fit  of 
coughing  and  vomiting,  which  caufed  the  vein  to  be 
forced  open,  and  he  loft  (agreeable  to  the  mother's 
information)  near  five  ounces  of  blood ;  after  which 
he  refted  very  well  all  night.  At  eight  o'clock  on 
the  morning  of  the  21ft,  the  child  was  much  better 
in  every  refpect;  there  remained,  however,  fome 
degree  of  the  peculiar  found  of  the  voice ;  to  re- 
move which  we  directed  oxymel  frill,  one  tea-fpoon- 
ful  to  be  taken  every  hour.  This  had  the  happy  effect 
of  keeping  up  a  moifture  on  his  fkin,  and  caufed 
him  to  cough  up  a  considerable  quantity  of  ropy 

matter. 


(     3*     ) 

matter.  The  following  day  the  child  appeared  to 
be  perfectly  well,  and  continued  fo  without  the  aid 
of  any  other  remedies.. 


CASE    II. 


ON  the  1 8th  December,  1791,  I  was  fent  for 
to  fee  a  daughter  of  Mr.  James  M'Kay's,  who  was 
the  day  before  attacked  with  Cynanche  Trachealis. 
From  the  extreme  difficulty  of  breathing  that  ihe 
laboured  under,  I  thought  it  adyifable  to  let  *blood  j 
I  therefore  opened  a  vein,  and  fufrered  her  to  bleed' 
ad  deliquium.  After  me  recovered  from  the  fainting 
me  was  put  into  a  warm  bath,  and  puked  freely 
with  afolution  of  emetic  tartar,  which  hadlikewife 
the  beneficial  effect  of  producing  an  evacuation  from 
her  bowels.  Two  hours  after  I  vifited  her  again, 
and  finding  the  difficulty  of  breathing  not  altogether 
removed,  I  directed  the  emetic  folution  and  warm 
bath  to  be  repeated  j  at  the  fame  time  a  bliftering 
philter  was  applied  to  her  throat.  The  following 
day  her  bowels  were  opened  with  calomel,  and  on 
the  fourth  day  fhe  was  perfectly  well,  except  the 
forenefs  of  the  blifter, 

CASE 


(       32       ) 

CASE     III. 


A  child  of  Mr.  Walter  Reed's  was,  on  the  26th 
November,  1792,  feized  with  a  hoarfe,  dry  cough, 
and  laborious  refpiration.  The  following  day  I  was 
defired  to  vifit  him,  at  which  time  he  was  apparently 
in  the  greateft  diftrefs,  and,  in  fhort,  had  a  mod 
complete  Cynanche  1'racbealis.  I  immediately  open- 
ed a  vein  in  the  arm,  and  took  from  it  fix  ounces  of 
blood ;  on  which  he  (hewed  fymptoms  of  deliquium. 
He  theft  took  fmall  portions  of  emetic  tartar,  which 
caufed  him  to  throw  up  a  confiderable  quantity  of 
vifcid  matter.  The  warm  bath  was  then  ufed,  when 
his  fkin  became  moift,  and  he  paffed  feveral  large 
portions  of  a  membranous  lubftance  by  ftool.  The 
next  day  he  took  a  fmall  dofe  of  calomel,  which 
brought  away,  by  ftool,  a  great  quantity  of  the 
preternatural  membrane  •,  the  child  was  thereby 
greatly  relieved;  and  by  keeping  his  bowels  open 
with  calomel,  in  a  few  days  he  was  perfectly  reftored 
to  health. 


CASE 


(     33    ) 


CASE    IV. 

A  child  of  Mr.  Jacob  Brown's,  one  year  and  fevea 
months  old,  was  attacked  with  Cynanche  Trachealis. 
On  the  31ft  December,  1792,  at  eleven  o'clock  P. 
M.  I  was  requeued  to  vifit  him.  The  violence  of 
the  fymptoms  called  loudly  for  immediate  afliftance : 
I  therefore  opened  the  jugular  vein,  and  took  away, 
near  eight  ounces  of  blood-,  ordered  a  warm  bath, 
and  an  emetic  folution,  which  relieved  the  difficulty 
of  breathing,  caufed  him  to  heave  up  fome  vifcid 
matter,  and  like  wile  to  pafs  confiderable  in  his  ftools. 
The  fkin  appearing  to  be  dry,  I  dire&ed  the  bath 
to  be  repeated,  and  fmall  portions  of  the  emetic  to 
be  taken  in  fuch  a  manner  as  to  keep  up  a  conftant 
naufea.  The  third  day  the  child  was  perfectly  re- 
lieved of  the  difficulty  of  breathing,  and  in  a  few 
days  more  appeared  to  be  in  perfect  health.  About 
fix  weeks  after,  he  had  a  return  of  the  complaint, 
and  notwithfianding  every  thing  was  done  for  his  re- 
lief, he  died  on  the  fifth  day  of  the  difeafe. 


E  CASE 


t     34     )' 


CASE    V. 

MR.  John  Hilly er  called  on  me  the  26th  January, 
1793,  to  vifit  a  child  of  his  which  had  been  com- 
plaining for  feveral  days:  When  I  firft  faw  the 
child,  he  appeared  to  be  gafping  for  breath ;  his  face 
was  pale,  or  rather  inclining  to  a  livid  appearance ; 
his  pulfe  extremely  weak  and  frequent ;  in  fhort,  all 
thofe  fymptoms  appeared  which  accompany  what 
Home  calls  the  putrid  ftage  of  Cynanche  Trachealis. 
From  the  difeafe  having  been  of  feveral  days  Hand- 
ing, and  from  the  violence  of  the  fymptoms,  I  al- 
moin defpaired  of  faving  the  child.  Willing,  how- 
ever, to  give  him  every  poffible  chance  of  recovery, 
and  being  fully  fatisfied  that  putridity  was  not  the 
caufe  of  the  debility,  I  immediately  opened  one  of 
the  jugular  veins,  from  which  near  (even  ounces  of 
blood  were  drawn.  The  child  appeared  to  faint;  I 
then  flopped  the  blood,  and  on  recovering,  he 
breathed  much  more  eafy.  I  now  purfued  the  fame 
method  as  in  the  former  cafes,  with  refpect  to  the 
bath  and  emetics.  In  addition  to  which,  a  Witter- 
ing plainer  was  applied  to  the  throat,  and,  to  my 
great  fatisfaction,  after  feven  days  the  child  was  per- 
fectly relieved  of  the  complaint. 

In 


(     35     ) 

In  this  lafl  mentioned  cafe,  agreeable  to  the  opi- 
nion that  was  formerly  entertained  of  this  difeafe, 
antifeptics  mould  have  been  freely  adminiftered. 
What  would  have  been  the  confequence  of  mch  a 
.plan  ?  The  anfwer  is  plain — certain  death. 

After  having  given  the  plan  of  cure,  above  re- 
commended, fo  fatisfaclory  a  trial,  there  does  no 
longer  remain  a  doubt  with  me,  that  the  fuppofi- 
tion  of  this  difeafe  being  attended  with  putridity  is 
erroneous;  and  has  of  courfe  been  productive  of 
much  mifchief, 


FINIS. 


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